Title: Fracture Management of Gunshot Wounds to the Hand
Authors: Mark W. Kiehn, MD, Karol A. Gutowski, MD, Amit Mitra, MD
Gunshot wounds (GSW) of the hand have become common injuries at inner city trauma centers.1, 2 Principles for the management of these injuries have evolved from experience in the treatment of military wounds, often caused by high-velocity weapons in contaminated conditions. Such injuries were treated with extensive debridement and staged wound management that included delayed fracture fixation and bone grafting.3, 4 In contrast, civilian GSW are most often caused by low-velocity handguns, which cause a localized pattern of injury and usually occur under conditions of limited contamination. For cases of civilian upper extremity GSW, surgeons have advocated a trend toward limited debridement and early definitive care.1, 2, 4 - 7 The purpose of this paper is to evaluate the results of early definitive treatment of urban hand GSW fractures and to evaluate patient compliance and its affect on the management of hand GSW fractures.
Methods: A retrospective review was conducted of medical records of patients treated by the Department of Plastic and Reconstructive Surgery at Temple University Hospital, for hand GSW from January 1989 to December 1998. The incidence of hand fractures, means of fracture fixation, and incidence of infection were determined. Patterns of patient compliance with post-hospital follow-up were also studied.
Upon presentation to the hospital, patients underwent trauma and hand surgery evaluations. After clinical examination and x-rays, wounds were cleansed, and fractures were reduced and splinted. Intravenous antibiotics (cefazolin or vancomycin) and tetanus prophylaxis were administered. Patients with adequate fracture reduction and stability, without significant soft-tissue injury, were managed non-operatively. Patients with devascularized tissues requiring revascularization or amputation, need for soft-tissue coverage, significant fracture misalignment or instability, bone loss, tendon or ligament injury, or evidence of compartment syndrome were considered surgical candidates.
Results: Ninety-eight hand GSW fractures were treated in 72 patients (Fig. 1). Seventy-four percent of patients required surgical intervention and 25% of patients received definitive fracture care in the emergency department or intensive care unit. One patient refused care. Fracture fixation techniques included Kirschner wires, internal plates, external fixators, lag screws, and cerclage wires (Table 1). Some patients required more than one technique for fracture fixation. Eleven patients (15%) required more than one operation (5 patients – revision of soft-tissue coverage, 5 patients – revision of fracture fixation, 1 patient – soft-tissue coverage and revision of fracture fixation). Three patients (4%) underwent primary amputation of single digits. Three patients (4%) underwent bone grafting at the initial surgery. Five patients (7%) required an additional operation after discharge from the hospital (2 patients – arthrodesis, 3 patients – bone grafting). The average time from presentation to the hospital to surgical intervention was 2 days (range = 0 to 8 days) and the average hospital stay was 6 days (range = 0 to 32 days). Both times were influenced most by the presence and treatment of concomitant injuries to other areas of the body.
Two in-hospital and 4 post-hospital infections were diagnosed (Table 2), for an 8% total incidence. There was not an association between type of fixation device used and incidence of infection (Fischer’s Exact Test, p=0.630). All cases of infection were limited to superficial soft-tissues and resolved with antibiotic therapy. No case required surgical intervention or removal of a fixation device.
Following discharge from the hospital, only 11 patients (15%) returned to clinic until complete fracture healing was documented. Thirty-three patients (46%) followed-up initially and 28 patients (39%) were lost to follow-up upon discharge from the hospital. Nineteen patients (26%) were lost to follow-up with a removable fixation device in place.
Conclusion: Firearms create a wide variety of injuries to the hand, depending upon the type of weapon and the circumstances of wounding. Civilian gunshot wounds are generally caused by low velocity handguns, which typically cause a localized pattern of injury and limited tissue destruction. Such injuries can be managed like other open fractures, with many cases managed non-operatively. In most cases that are managed surgically, debridement should be limited and internal fixation is not contraindicated. In cases of extensive or contaminated wounds, such as those caused by shotguns or high-velocity weapons, more extensive debridement and a staged approach to reconstruction is warranted. In such cases, definitive fixation and bone grafting should be delayed until the wound is controlled for contamination and soft-tissue coverage has been achieved.
In this study, infections were infrequent and comparable to rates of other types of open fractures.8 Though the use of transcutaneous fixation devices and open wound management are associated with low rates of infection in compliant patient populations,3, 8 their use may increase the risk of infection in the generally non-compliant urban trauma population, in which pin-site and wound care are apt to be neglected. Because the infections involved only superficial tissues and responded to antibiotic therapy alone, a more aggressive approach to debridement and soft-tissue coverage would have increased the complexity of management without significantly improving patient outcomes.
The treating surgeon should anticipate poor compliance from patients treated for GSW of the hand. The surgeon should attempt to accomplish the treatment goals in a limited number of surgeries and focus the treatment plan to meet the patient’s goals. The choice of fixation device should limit the need for device care and removal and have limited susceptibility to manipulation by the patient. Limiting joint immobilization may improve hand function for patients who are unlikely to participate in postoperative hand therapy.
Number of Patients
Kirschner Wires / 33Internal Plates / 16
External Fixation / 12
Screws or Cerclage / 4
Splint / 18
Table 1. Fixation Techniques for Fracture Management
Method of Fixation / Number of InfectionsKirschner Wires / 2/33 (6%)
Internal Plates / 2/16 (13%)
External Fixation / 2/12 (16%)
Screws or Cerclage / 0
Splint / 0
Table 2. Incidence of Superficial Infection Among Fixation Techniques
References
1. Gonzalez, M.H., McKay, W., and Hall, R.F. Jr: Low-velocity gunshot wounds of the metacarpal: Treatment by early stable fixation and bone grafting; J Hand Surg; 18A; 267-270; 1993.
2. Phillips, P. III, Hansraj, K.K., Cox, E.E. II, and Ashley, E.M: Gunshot wounds to the hand: The Martin Luther King, Jr, General Hospital experience; Orthop Clin North Am; 26; 95-108, 1995.
3. Burkhalter, W.E., Butler, B., Metz, W., Omer, G: Experiences with delayed primary closure of war wounds of the hand in Viet Nam; J Bone Joint Surg; 50A; 945-954; 1968.
4. Hennesey, M.J., Banks, H.H., Leach, R.B., and Quigley, T.B: Extremity gunshot wound and gunshot fracture in civilian practice; Clin Orthop; 114; 296-303; 1976.
5. Nathan, R: The management of penetrating trauma to the hand; Hand Clinics; 15; 193-199; 1999.
6. Hampton, O: The indications for debridement of gun shot (bullet) wounds of the extremities in civilian practice; J Trauma; 4; 368-372; 1961.
7. Bowyer, G.W., and Rossiter, N.D: Management of gunshot wounds of the limbs; J Bone Joint Surg; 79(B); 1031-1036; 1997.
8. Swanson, T.V., Szabo, R.M., and Anderson, D.D. Open hand fractures: Prognosis and classification; J Hand Surg; 16A; 101-107; 1991.